Does Allergic Bronchopulmonary Aspergillosis (ABPA) ever resolve?

From the Guidelines

Allergic bronchopulmonary aspergillosis (ABPA) can resolve with appropriate treatment, but it often requires long-term management rather than achieving complete cure. The most recent and highest quality study, published in the European Respiratory Journal in 2024 1, provides guidelines for diagnosing, classifying, and treating ABPA. According to these guidelines, treatment typically involves oral corticosteroids, such as prednisone, starting at 0.5 mg/kg/day for 1-2 weeks, then gradually tapered over 2-3 months, to reduce inflammation, and antifungal medications like itraconazole, 200 mg twice daily for 16-24 weeks, to decrease fungal burden.

Key Considerations

• In severe or refractory cases, newer antifungals like voriconazole or posaconazole may be used 2.
• Anti-IgE therapy with omalizumab has shown promise in some patients, particularly those with treatment-dependent ABPA 3.
• Even with successful treatment, ABPA tends to follow a relapsing and remitting course, with many patients experiencing recurrent flares requiring repeated treatment cycles.
• Some patients achieve long-term remission, particularly those with early diagnosis and aggressive initial treatment.

Management and Monitoring

• Regular monitoring of symptoms, pulmonary function, and specific biomarkers (total IgE levels, Aspergillus-specific antibodies) is essential to detect and treat relapses promptly 4.
• The underlying conditions that predispose to ABPA, such as asthma or cystic fibrosis, typically persist and require ongoing management even when ABPA is controlled.
• During remission, patients should be managed for underlying asthma and bronchiectasis, and monitored with clinical review, serum total IgE levels, and lung function tests every 3-6 months for the first year and then every 6-12 months.

From the Research

Resolution of Allergic Bronchopulmonary Aspergillosis (ABPA)

• ABPA is a complex condition, and its resolution is not always guaranteed, as evidenced by a case report where a patient experienced a recurrence of ABPA after surgical resection of aspergilloma 5.
• However, some studies suggest that treatment with antifungal agents such as itraconazole can lead to clinical, biological, and functional improvement in patients with ABPA, and may even allow for the reduction or elimination of glucocorticoid therapy 6, 7.
• In some cases, treatment with mepolizumab, an anti-interleukin-5 monoclonal antibody, has been shown to be effective in controlling ABPA symptoms and reducing the need for oral corticosteroids 8.
• The use of antifungal therapies, such as itraconazole, has been proposed as an alternative treatment for ABPA, particularly in patients with cystic fibrosis, although more research is needed to fully evaluate its effectiveness 9.

Factors Affecting Resolution of ABPA

• The presence of concomitant aspergilloma may affect the resolution of ABPA, as surgical resection of aspergilloma may be necessary to achieve resolution 5.
• The use of oral corticosteroids may be necessary to control ABPA symptoms, but their long-term use can impose a risk of adverse effects, such as the onset of nontuberculous mycobacterial infection 8.
• The type and duration of antifungal therapy may also affect the resolution of ABPA, with itraconazole being the most active azole compound against Aspergillus fumigatus 6, 7, 9.